Sidney Jenkins

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Sidney Jenkins,
a prisoner at HMP Dartmoor,
on 15 September 2022
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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Summary
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways
in which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr Sidney Jenkins died in hospital on 15 September 2022 of pneumonia and lung
cancer while a prisoner at HMP Dartmoor. He was 80 years old. We offer our
condolences to Jenkins’ family and friends.
4. The clinical reviewer concluded that the care Mr Jenkins received at Dartmoor was
equivalent to that which he could have expected to receive in the community. She
makes four recommendations for the Head of Healthcare to improve compliance
with national clinical guidelines.
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The Investigation Process
5. NHS England commissioned an independent clinical reviewer to review Mr Jenkins’
clinical care at Dartmoor.
6. The PPO investigator investigated the non-clinical issues relating to Mr Jenkins’
care, including Mr Jenkins’ location, the security arrangements for his hospital
escorts, liaison with his family and whether compassionate release was considered.
7. The PPO family liaison officer wrote to Mr Jenkins’ next of kin, his wife, to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not respond to our letter.
8. The prison received a copy of the report. They did not identify any factual
inaccuracies.
Previous deaths at HMP Dartmoor
9. Mr Jenkins was the seventh prisoner to die at Dartmoor since September 2020. Of
the previous deaths, five were from natural causes and one was self-inflicted.
There are no similarities between our findings in the investigation into Mr Jenkins’
death and our investigation findings for the previous deaths. Since Mr Jenkins’
death, three prisoners have died. Of these deaths, two were from natural causes
and one was self-inflicted.
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Key Events
10. On 18 January 2019, Mr Sydney Jenkins was remanded to HMP Exeter. On 25
January 2019, he was sentenced to 18 years in prison for sexual offences.
11. On 8 March, Mr Jenkins transferred to HMP Dartmoor. At his initial healthcare
screening, healthcare staff recorded that Mr Jenkins had diabetes, high blood
pressure and chronic obstructive pulmonary disease (COPD). Healthcare staff put
a summary care plan in place (a general care plan for older patients with multiple
chronic conditions) for Mr Jenkins.
12. Between March 2019 and December 2021, healthcare recorded no significant
events or concerns about Mr Jenkins. On 13 December 2021, Mr Jenkins told a
prison GP that he had chest pain. The GP referred him for a chest x-ray.
13. On 13 January 2022, Mr Jenkins attended hospital for his chest x-ray. On 17
January 2022, a prison GP reviewed Mr Jenkins’ x-ray, which showed a cavity in
the lower right lung. The prison GP referred Mr Jenkins to the hospital respiratory
clinic.
14. On 3 March, Mr Jenkins had a CT scan (a series of x-ray images taken from
different angles).
15. On 15 March, Mr Jenkins attended the hospital respiratory clinic to discuss his CT
scan results. The consultant concluded that the abnormalities on the scans could
be due to infection or cancer and needed further investigation.
16. On 13 April, Mr Jenkins attended the hospital for an endobronchial ultrasound (a
procedure to look at the lungs). On 27 April, Mr Jenkins had a second follow-up
endobronchial ultrasound.
17. On 4 May, the hospital confirmed that Mr Jenkins’ endobronchial ultrasounds had
shown lung cancer, which had spread to one of his lymph glands. They planned to
operate on Mr Jenkins, to remove his cancer, if he passed a lung and heart function
test.
18. On 20 June, Mr Jenkins attended hospital for his lung and heart function test. The
consultant concluded that his function was good, and the risk of complications was
low if Mr Jenkins had surgery to remove his cancer.
19. On 21 June, Mr Jenkins attended hospital for an MRI scan (a detailed scan of the
body) to check that the cancer had not spread to his brain. The scan confirmed that
the cancer had not spread to Mr Jenkins’ brain.
20. On 12 July, Mr Jenkins tested positive for Covid-19. He isolated in accordance with
guidelines until he tested negative on 25 July. Healthcare staff did not record any
concerns.
21. On 2 August, Mr Jenkins attended hospital for an appointment with the pre-
operation clinic. The consultant requested an up-to-date CT scan.
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22. On 12 August, Mr Jenkins attended hospital for a CT scan, which showed that the
cancer had spread to other lymph nodes and his brain.
23. On 14 August, Mr Jenkins told a prison nurse that he had chest pain. The nurse
called a code blue (an emergency radio code which communicates that a prisoner
is not breathing) and paramedics took him to hospital. Healthcare staff stated that
they had no medical objections to officers using cuffs to restrain Mr Jenkins while at
hospital and the Duty Governor authorised the use of a single cuff. Mr Jenkins
stayed in hospital overnight and returned to Dartmoor the next day.
24. On 25 August, a hospital consultant informed contacted a prison GP at Dartmoor
and confirmed that Mr Jenkins’ recent tests had shown his cancer had grown. They
could no longer operate to remove the cancer. They referred Mr Jenkins to an
oncology consultant for possible palliative chemotherapy.
25. On 29 August, the chaplain at Dartmoor met with Mr Jenkins to discuss his final
wishes.
26. At 11.30pm on 4 September, Mr Jenkins told prison staff that he was experiencing
chest pain again. They called a code blue and paramedics took him to hospital.
There were no healthcare staff on site at the time, so healthcare staff could not be
consulted about any medical objections to restraining Mr Jenkins. The Duty
Governor authorised the use of a single cuff to restrain Mr Jenkins while in hospital.
He stayed as an inpatient until he died.
27. On 5 September, Dartmoor’s Custodial Discharge Co-ordinator discussed Mr
Jenkins’ health with hospital staff. Hospital staff said that although Mr Jenkins was
very unwell, they were still giving him active treatment and were not giving him end
of life care.
28. On 8 September, hospital staff told Dartmoor that Mr Jenkins had contracted
pneumonia and they were treating him with antibiotics. The Duty Governor
reassessed Mr Jenkins’ risk of escape and risk of reoffending against his
deteriorating health condition and his lack of mobility and decided to remove the
cuffs.
29. On 12 September, a hospital consultant recorded that Mr Jenkins was developing
sepsis (the body’s extreme response to an infection). After a discussion with the
cancer nurse, Mr Jenkins said he did not want anyone to resuscitate him if his heart
or breathing stopped and signed an order to that effect. Dartmoor’s Custodial
Discharge Co-ordinator started the early release on compassionate grounds
process.
30. At 5.30am on 15 September, Mr Jenkins died.
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Post-mortem report
31. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr Jenkins’ cause of death
as pneumonia caused by lung cancer which had spread to the brain. Heart disease,
Covid-19 and chronic obstructive pulmonary disease (COPD) were listed as
contributory factors.
Inquest
32. The inquest into Mr Jenkins’ death concluded on 1 December 2025, recording a
verdict of natural causes.
Tallulah Frankland
Assistant Ombudsman April 2023
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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